A plea for long term counselling to be included in provision of services

When a colleague and I decided to set up a project in Bristol to help anyone wanting to change their alcohol use we did so with all the accumulated knowledge from our counselling / psychotherapy training as well as our experience from working in the field. Therefore long term counselling quickly became one of our aims even though the service that was usually purchased was for short-term counselling. By long-term counselling I mean anything over a year. We provide rigorous training and the amount of supervision required by the British Association for Counselling and Psychotherapy for our students who come to us on placement and we ask all our service users to make a contribution to the service. This cost varies from between £2-£25 depending on means. Since we achieved charitable status this has been supplemented by various small donations from various sources. We are now in a position where we can provide a sustainable service providing long-term counselling without receiving any government money.

We do not believe that long-term counselling is the answer for every service user as many are not yet in the right place to make that commitment or to even want to look at past issues or engage long term. However at the SWAN Project we have seen many who have been revolving door clients, who have tried other modalities many times, and who after long-term counseling are transformed and finding their way back to independent living, finding employment and best of all enjoying their lives.

Since we set up The SWAN Project counselling provision has become more common, but too rarely is counselling offered for long enough to provide the service user with the opportunity to build up true trust with their counsellor, to reduce or destroy feelings of shame, deal with the issues that substance misuse is helping them to cope with - often coming from their childhood, to allow them to internalise a sense of containment and to increase their self-esteem and sense of their self-efficacy to the point where they are able to take responsibility for their own actions. We believe that long-term counselling can achieve all these aims.

We feel that there are limiting misconceptions about what counselling is. It is often seen as just a place to talk through childhood issues. Within the field of substance misuse we feel that this is not only a limited view but can also be a dangerous one as this aspect of counselling can only safely take place once someone knows how sit with the feelings that arise or is able to ground themselves

Counselling is multi-faceted and different aspects of it are used according to where someone sits on the Cycle of Change. While someone is still drinking, for example, counselling focuses on collecting information about the amount being consumed while linking it with thoughts and actions that are occurring at the time, identifying cues and triggers, exploring strategies to help break habits and helping to construct manageable plans to cut back or stop. Once the client is abstinent or has reached his/her desired goal counselling can support the client to come up with plans to get through the next few hours/ days, exploring ways to cope with difficult situations and generally to prevent a lapse. All these things can be done very effectively working short-term. However, this has its limitations as the service user is still left with the issues that underlie his/her addictive habit.

Maybe treatment plans have given too much priority to focusing on the environment to keep our service users safe with out looking enough at what is going on in their internal worlds – their perceptions, how they experience situations and their relationships. It is easy for an addict to remain on the straight a narrow while they are in a residential rehab, attending a day programme or living in supported housing. Their anxiety levels will remain low as their feelings are being contained - made manageable - by the perceived support. However, when they leave the safe environment how can they manage their feelings if they become overwhelming without regressing back to old strategies of using or drinking which worked for them in the past? At the SWAN Project we believe that long term counselling which provides repeated experiences of containment, of emotional soothing, becomes internalised eventually giving the service user the ability to self-soothe. Also by working through the issues that are underlying the using clients are much less likely to be overwhelmed.

Long-term counselling allows time for the counsellor and the client to build trust and mutual respect for each other. The majority of those who misuse substances hold a lot of shame not only about their drug use, sometimes about criminal activity used to support their habit or sometimes about unsocial behaviour while under the influence but also often about their pasts or present experiences of abuse, neglect, adoption, sexuality difficulties and so on. At present many services are only commissioned to provide such short-term counselling that service users often either feel they need to talk about issues for which they are not ready and then feel bad about themselves, or even worse, are re-traumatised. It takes time to break down the barrier that shame erects. When we feel we are a bad person it is difficult to expose ourselves to another for fear of being judged and/or rejected. The non-judgmental position of the counsellor together with the normalising process can over time slowly alleviate shame. As one of the main defences against shame is to place the responsibility for the action elsewhere it is impossible for a person holding lots of shame to take responsibility for their own behaviour.

Emotional immaturity is often the reason why individuals misuse substances– they have difficulty dealing with their emotions, often anxiety of some kind. They have no, few or inadequate ways to self-soothe. When someone has been clean or dry for a period of time the counsellor can teach them how to ground themselves - learn how to bring themselves back to the present moment rather than being trapped in old redundant emotions triggered by every day events.

People who have had good enough experiences while growing up are able to feel secure inside because they have experienced the environment as nurturing and this has been internalised and is carried with them through life as an internalised representation of how life is. If we have not then our inner representation of the world is poisonous or dangerous. It is hard to trust that good things will happen to us as our experience has confirmed the opposite. In our experience it takes over a year for this internal view to change and it happens by experiencing a good-enough relationship that is empathic, supportive, honest, non-judgemental and consistent.

Emotional literacy can be encouraged by several means. By using congruence about the emotions aroused in the counsellor the feedback to the service user can help them to get in touch with their own feelings and to find names for them. It can also normalise the emotion aroused and can demonstrate the usefulness of that emotion. For example, when someone talks about how their flatmate is driving them mad, the counsellor by reflecting back the anger she is feeling normalises anger in that situation. Then the situation that aroused the anger can be explored and the anger can be seen as an emotion that helps us to hold our boundaries. The anger becomes manageable and even useful. The aim is for service users to have the experience that feelings are safe and that even overwhelming ones can be survived without the use of a substance. Service users can vent emotionally difficult situations and have them contained by the counsellor. If this containment is experienced repeatedly it is internalised and helps the service user to become more adept at containing themselves, at managing their emotional state..

The core conditions of counselling – expressing empathy, being non-judgemental and congruent – allow shame to disintegrate as either feelings and behaviours are normalised or the shame is passed to the rightful owner – the abuser. Self-esteem grows and self-doubt diminishes People are able and have the confidence to take responsibility for themselves.

Issues that have not been finished and have not been processed, return to catch us unawares. An everyday situation may trigger a past emotion which can engulf us. For this reason it is good to talk about and process past events.Once the service user is able to ground him self and the therapeutic relationship is containing then it is possible to look back at childhood issues knowing that safety can quickly be re-established should emotions start to become overwhelming.

The main focus of rehabilitation is on new ways to use behaviour but when we educate people about self-esteem, emotional management, how to be assertive and so on we are connecting with their intellects. We are asking them to use a technique without it being fully integrated. At the SWAN Project we believe that having the knowledge of how to be assertive, for example, but without it being properly integrated can lower self esteem as the individual fails to say ‘no’ yet again. Once a service user has found self-acceptance, self-respect and gained self-esteem many of these ways healthy ways of being come naturally. If the service user is receiving long term counselling these aspects are naturally integrated into behaviours rather than being more like an appendage – an unintegrated part of themselves.

I appreciate that to a large extent these ideas are not new, but instead of those counsellors working in this field feeling frustrated and dissatisfied y the length with which they can work with a client maybe now is a good time to give these ideas more of a public airing.

To summarise, short-term counselling is effective for helping service users to stop using or drinking and equips them for some strategies around relapse prevention. However, it will not be able to address the problems underlying the using or drinking and so relapse is much more likely than were this not the case. Counselling can only help service users to process issues from the past if it is long term. This allows time for trust and mutual respect in the therapeutic relationship to develop, for shame to diminish, for self-soothing to be accomplished and for an internalisation of the counsellor as an example of a nurturing relationship to take place. In this scenario self-esteem, self-efficacy, management of emotions and assertiveness are integrated into the core self rather than remaining as an intellectual ideal. Once shame diminishes, self-esteem grows and self-doubt diminishes, people are able and have the confidence to take responsibility for their actions.

Ronnie Aaronson is Founder and Co-project leader of The SWAN Project in Bristol. She also supervises in several other alcohol and drug organizations. Author of Addiction – This being human.